chronic obstructive lung disease (copd), … · globally, the copd burden is projected to increase...

CHRONIC OBSTRUCTIVE LUNG CHRONIC OBSTRUCTIVE LUNG DISEASE (COPD), BRONCHIAL DISEASE (COPD), BRONCHIAL

ASTHMAASTHMA

GOLD GINAGOLD GINA

Chronic Obstructive Pulmonary Disease (COPD)

© 2017 Global Initiative for Chronic Obstructive Lung Disease

► COPD is currently the fourth leading cause of death in the world.1

► COPD is projected to be the 3rd leading cause of death by 2020.2

► More than 3 million people died of COPD in 2012 accounting for 6% of all deaths globally.

► Globally, the COPD burden is projected to increase in coming decades because of continued exposure to COPD risk factors and aging of the population.

1. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380(9859): 2095-128.

2. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006; 3(11): e442.

Economic and Social Burden


Economic burden of COPD

►COPD is associated with significant economic burden. ► COPD exacerbations account for the greatest

proportion of the total COPD burden.

►European Union: Direct costs of respiratory disease ~6% of

the total healthcare budget COPD accounting for 56% (38.6 billion

Euros) of the cost of respiratory disease.

►USA: Direct costs of COPD are $32 billion Indirect costs $20.4 billion.

COPD DefinitionCOPD Definition

Chronic Obstructive Pulmonary Disease Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and (COPD) is a common, preventable and treatable disease that is characterized by treatable disease that is characterized by persistent respiratory symptoms and persistent respiratory symptoms and airflow limitationairflow limitation that is due to airway that is due to airway and/or alveolar abnormalities usually and/or alveolar abnormalities usually caused by significant exposure to noxious caused by significant exposure to noxious particles or gases. particles or gases.

Factors that influence disease progression


► Genetic factors

► Age and gender

► Lung growth and development

► Exposure to particles

► Socioeconomic status

► Asthma & airway hyper-reactivity

► Chronic bronchitis

► Infections

Global Strategy for Diagnosis, Management and Prevention of COPD

Risk Factors for COPD

GenesGenes

InfectionsInfections

Socio-economic Socio-economic statusstatus

Aging PopulationsAging Populations© 2015 Global Initiative for Chronic Obstructive Lung Disease

Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK

Clinical forms of COPDClinical forms of COPD

Pink puffer

Blue bloater

Medical History


► Patient’s exposure to risk factors

► Past medical history

► Family history of COPD or other chronic respiratory disease.

► Pattern of symptom development

► History of exacerbations or previous hospitalizations for respiratory disorder

► Presence of comorbidities

► Impact of disease on patient’s life

► Social and family support available to the patient.

► Possibilities for reducing risk factors, especially smoking cessation.

Diagnosis and Initial Assessment


Assessment of COPDAssessment of COPD

Assess symptomsAssess symptoms

Assess degree of airflow Assess degree of airflow limitation using spirometrylimitation using spirometry

Assess risk of exacerbationsAssess risk of exacerbations

Assess comorbiditiesAssess comorbidities© 2015 Global Initiative for Chronic Obstructive Lung Disease

The characteristic symptoms of COPD are chronic and progressive dyspnea, cough, and sputum production that can be variable from day-to-day.

Dyspnea: Progressive, persistent and characteristically worse with exercise.

Chronic cough: May be intermittent and may be unproductive.

Chronic sputum production: COPD patients commonly cough up sputum.

Symptoms of COPD


Assess symptomsAssess symptomsAssess degree of airflow limitation using Assess degree of airflow limitation using spirometryspirometry

Assess risk of exacerbationsAssess risk of exacerbations

Assess comorbiditiesAssess comorbidities

COPD Assessment Test (CAT)

or

Clinical COPD Questionnaire (CCQ)

or

mMRC Breathlessness scale

Global Strategy for Diagnosis, Management and Prevention of Global Strategy for Diagnosis, Management and Prevention of COPDCOPD

Assessment of COPDAssessment of COPD


Global Strategy for Diagnosis, Management and Prevention of COPD

Classification of Severity of Airflow Limitation in COPD*

In patients with FEV1/FVC < 0.70:

GOLD 1: Mild FEV1 > 80% predicted

GOLD 2: Moderate 50% < FEV1 < 80% predicted

GOLD 3: Severe 30% < FEV1 < 50% predicted

GOLD 4: Very Severe FEV1 < 30% predicted

*Based on Post-Bronchodilator FEV1


Spirometry


Global Strategy for Diagnosis, Management and Prevention Global Strategy for Diagnosis, Management and Prevention of COPDof COPD

Assess Risk of Assess Risk of ExacerbationsExacerbationsTo assess risk of exacerbations use To assess risk of exacerbations use

history of exacerbations and spirometry: history of exacerbations and spirometry:

Two or more exacerbations within the Two or more exacerbations within the last year last year oror an FEV an FEV1 1 < 50 % of predicted < 50 % of predicted value are indicators of high risk.value are indicators of high risk.

One or more hospitalizations for COPD One or more hospitalizations for COPD exacerbation should be considered high exacerbation should be considered high risk.risk.


Assessment of Exacerbation Risk


► COPD exacerbations are defined as an acute worsening of respiratory symptoms that result in additional therapy.

► Classified as: Mild (treated with SABDs only) Moderate (treated with SABDs plus antibiotics

and/or oral corticosteroids) or Severe (patient requires hospitalization or visits

the emergency room). Severe exacerbations may also be associated with acute respiratory failure.

► Blood eosinophil count may also predict exacerbation rates (in patients treated with LABA without ICS).

Differential Diagnosis

Prevention & Maintenance Therapy (1)


►Smoking cessation is key. Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates.

►The effectiveness and safety of e-cigarettes as a smoking cessation aid is uncertain at present.

►Pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance.

►Each pharmacologic treatment regimen should be individualized and guided by the severity of symptoms, risk of exacerbations, side-effects, comorbidities, drug availability and cost, and the patient’s response, preference and ability to use various drug delivery devices.

►Inhaler technique needs to be assessed regularly.

Prevention & Maintenance Therapy (2)


►Influenza vaccination decreases the incidence of lower respiratory tract infections.

►Pneumococcal vaccination decreases lower respiratory tract infections.

►Pulmonary rehabilitation improves symptoms, quality of life, and physical and emotional participation in everyday activities.

►In patients with severe resting chronic hypoxemia, long-term oxygen therapy improves survival.

►In patients with stable COPD and resting or exercise-induced moderate desaturation, long-term oxygen treatment should not be prescribed routinely. However, individual patient factors must be considered when evaluating the patient’s need for supplemental oxygen.

Global Strategy for Diagnosis, Management and Prevention of Global Strategy for Diagnosis, Management and Prevention of COPDCOPD

Manage Stable COPD: Pharmacologic Manage Stable COPD: Pharmacologic TherapyTherapy

((Medications in each box are mentioned in alphabetical order, and therefore Medications in each box are mentioned in alphabetical order, and therefore not necessarily in order of preference.)not necessarily in order of preference.)

Patient RecommendedFirst choice

Alternative choice Other PossibleTreatments

ASAMA prn

or SABA prn

LAMA or

LABA or

SABA and SAMA

Theophylline

BLAMA

or LABA

LAMA and LABASABA and/or SAMA

Theophylline

C

ICS + LABAor

LAMA

LAMA and LABA orLAMA and PDE4-inh. orLABA and PDE4-inh.

SABA and/or SAMATheophylline

D

ICS + LABAand/or LAMA

ICS + LABA and LAMA or ICS+LABA and PDE4-inh. or

LAMA and LABA orLAMA and PDE4-inh.

CarbocysteineN-acetylcysteine

SABA and/or SAMATheophylline

Treatment of Stable COPDTreatment of Stable COPD

Model for the initiation, and then subsequent escalation and/or de-

escalation of pharmacologic management of COPD according to

the individualized assessment of symptoms and exacerbation risk

(GOLD 2017)

Treatment of Stable COPD


Pharmacologic Therapy


Non-Pharmacologic Treatment


►Education and self-management

►Physical activity

►Pulmonary rehabilitation programs

►Exercise training

►Self-management education

►End of life and palliative care

►Nutritional support

►Vaccination

►Oxygen therapy

Global Strategy for Diagnosis, Management and Prevention Global Strategy for Diagnosis, Management and Prevention of COPDof COPD

Manage Stable COPD: Non-Manage Stable COPD: Non-pharmacologicpharmacologic

PatientGroup

Essential Recommended Depending on local guidelines

ASmoking cessation (can include pharmacologic

treatment)Physical activity

Flu vaccinationPneumococcal

vaccination

B, C, D

Smoking cessation (can include pharmacologic

treatment)Pulmonary rehabilitation

Physical activityFlu vaccinationPneumococcal

vaccination




Oxygen therapy

Long-term oxygen therapy is indicated for stable patients who have:

►PaO2 at or below 7.3 kPa (55 mmHg) or SaO2 at or below 88%, with or without hypercapnia confirmed twice over a three week period; or

►PaO2 between 7.3 kPa (55 mmHg) and 8.0 kPa (60 mmHg), or SaO2 of 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit > 55%).

Management of Exacerbations


COPD exacerbations are defined as an acute worsening of respiratory symptoms that result in additional therapy.

►They are classified as:

Mild (treated with short acting bronchodilators only, SABDs)

Moderate (treated with SABDs plus antibiotics and/or oral corticosteroids) or

Severe (patient requires hospitalization or visits the emergency room). Severe exacerbations may also be associated with acute respiratory failure.

Oxygen: titrate to improve the patient’s hypoxemia with a target saturation of 88-92%. Bronchodilators: Short-acting inhaled beta2-agonists with or without short-acting anticholinergics are preferred. Systemic Corticosteroids: Shorten recovery time, improve lung function (FEV1) and arterial hypoxemia (PaO2), and reduce the risk of early relapse, treatment failure, and length of hospital stay. A dose of 40 mg prednisone per day for 5 days is recommended. Nebulized magnesium as an adjuvent to salbutamol treatment in the setting of acute exacerbations of COPD has no effect on FEV1.

Global Strategy for Diagnosis, Management and Prevention of COPDGlobal Strategy for Diagnosis, Management and Prevention of COPD

Manage Exacerbations: Treatment Manage Exacerbations: Treatment OptionsOptions


Antibiotics should be given to patients with:

Three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence.

Who require mechanical ventilation.

Global Strategy for Diagnosis, Management and Prevention of COPDGlobal Strategy for Diagnosis, Management and Prevention of COPD

Manage Exacerbations: Treatment Manage Exacerbations: Treatment OptionsOptions




Classification of hospitalized patients

Acute respiratory failure — life-threatening: Respiratory rate: > 30 breaths per minute; using accessory respiratory muscles; acute changes in mental status; hypoxemia not improved with supplemental oxygen via Venturi mask or requiring FiO2 > 40%; hypercarbia i.e., PaCO2 increased compared with baseline or elevated > 60 mmHg or the presence of acidosis (pH < 7.25).

Asthma is a common and potentially serious chronic disease Asthma is a common and potentially serious chronic disease that that can be controlled but not cured can be controlled but not cured (and is unlikely ever to go (and is unlikely ever to go into complete remission)into complete remission)

Symptoms are associated with Symptoms are associated with variable expiratory airflowvariable expiratory airflow, i.e. , i.e. difficulty breathing air out of the lungs due to difficulty breathing air out of the lungs due to Bronchoconstriction (airway narrowing)Bronchoconstriction (airway narrowing) Airway wall thickeningAirway wall thickening Increased mucusIncreased mucus

Symptoms may be triggered or worsened by factors such as Symptoms may be triggered or worsened by factors such as viral infections, allergens, tobacco smoke, exercise and stressviral infections, allergens, tobacco smoke, exercise and stress

What is known about asthma?What is known about asthma?

GINA 2016

Asthma is a heterogeneous disease, usually Asthma is a heterogeneous disease, usually characterized by characterized by chronic airway inflammationchronic airway inflammation. .

It is defined by the history of respiratory symptoms It is defined by the history of respiratory symptoms such as such as wheeze, shortness of breath, chest tightness wheeze, shortness of breath, chest tightness and cough and cough that that vary over time and in intensityvary over time and in intensity..

Definition of asthmaDefinition of asthma

GINA 2016

Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK

IncreasedIncreased probability that symptoms are due to asthma if: probability that symptoms are due to asthma if: More than one type of symptom (wheeze, shortness of breath, More than one type of symptom (wheeze, shortness of breath,

cough, chest tightness)cough, chest tightness) Symptoms often worse at night or in the early morningSymptoms often worse at night or in the early morning Symptoms vary over time and in intensitySymptoms vary over time and in intensity Symptoms are triggered by viral infections, exercise, allergen Symptoms are triggered by viral infections, exercise, allergen

exposure, changes in weather, laughter, irritants such as car exposure, changes in weather, laughter, irritants such as car exhaust fumes, smoke, or strong smellsexhaust fumes, smoke, or strong smells

DecreasedDecreased probability that symptoms are due to asthma if: probability that symptoms are due to asthma if: Isolated cough with no other respiratory symptomsIsolated cough with no other respiratory symptoms Chronic production of sputumChronic production of sputum Shortness of breath associated with dizziness, light-headedness Shortness of breath associated with dizziness, light-headedness

or peripheral tinglingor peripheral tingling Chest painChest pain Exercise-induced dyspnea with noisy inspiration (stridor)Exercise-induced dyspnea with noisy inspiration (stridor)

Diagnosis of asthma – Diagnosis of asthma – symptomssymptoms

GINA 2017

© Global Initiative for Asthma

Confirm presence of airflow limitation Document that FEV1/FVC is reduced (at least once, when FEV1 is low) FEV1/ FVC ratio is normally >0.75 – 0.80 in healthy adults, and

>0.90 in children Confirm variation in lung function is greater than in healthy individuals

The greater the variation, or the more times variation is seen, the greater probability that the diagnosis is asthma

Excessive bronchodilator reversibility (adults: increase in FEV1 >12% and >200mL; children: increase >12% predicted)

Excessive diurnal variability from 1-2 weeks’ twice-daily PEF monitoring (daily amplitude x 100/daily mean, averaged)

Significant increase in FEV1 or PEF after 4 weeks of controller treatment

If initial testing is negative:• Repeat when patient is symptomatic, or after withholding

bronchodilators• Refer for additional tests (especially children ≤5 years, or the elderly)

Diagnosis of asthma – variable airflow limitation

GINA 2017, Box 1-2


Physical examination in people with asthma

Often normal The most frequent finding is wheezing on auscultation,

especially on forced expiration Wheezing is also found in other conditions, for example:

Respiratory infections COPD Upper airway dysfunction Endobronchial obstruction Inhaled foreign body

Wheezing may be absent during severe asthma exacerbations (‘silent chest’)

Diagnosis of asthma – physical examination

GINA 2017


1. Asthma control - two domains Assess symptom control over the last 4 weeks Assess risk factors for poor outcomes, including low

lung function2. Treatment issues

Check inhaler technique and adherence Ask about side-effects Does the patient have a written asthma action plan? What are the patient’s attitudes and goals for their asthma?

3. Comorbidities Think of rhinosinusitis, GERD, obesity, obstructive sleep apnea,

depression, anxiety These may contribute to symptoms and poor quality of life

Assessment of asthma

GINA 2017, Box 2-1


GINA assessment of asthma control

A. Symptom control

In the past 4 weeks, has the patient had:Well-

controlledPartly

controlledUncontrolled

• Daytime asthma symptoms more than twice a week?

Yes No

None of these

1-2 of these

3-4 of these

• Any night waking due to asthma?

Yes No

• Reliever needed for symptoms* more than twice a week?

Yes No

• Any activity limitation due to asthma?

Yes No

B. Risk factors for poor asthma outcomes• Assess risk factors at diagnosis and periodically• Measure FEV1 at start of treatment, after 3 to 6 months of treatment to record the patient’s

personal best, then periodically for ongoing risk assessmentASSESS PATIENT’S RISKS FOR:• Exacerbations• Fixed airflow limitation• Medication side-effects

GINA 2017 Box 2-2B (1/4)

Level of asthma symptom control


Assessment of risk factors for poor asthma outcomes

GINA 2017, Box 2-2B (4/4)

Risk factors for exacerbations include:

• Ever intubated for asthma• Uncontrolled asthma symptoms• Having ≥1 exacerbation in last 12 months• Low FEV1 (measure lung function at start of treatment, at 3-6 months

to assess personal best, and periodically thereafter)• Incorrect inhaler technique and/or poor adherence• Smoking• Elevated FeNO in adults with allergic asthma• Obesity, pregnancy, blood eosinophilia

Risk factors for fixed airflow limitation include:

• No ICS treatment, smoking, occupational exposure, mucus hypersecretion, blood eosinophilia

Risk factors for medication side-effects include:

• Frequent oral steroids, high dose/potent ICS, P450 inhibitors


How? Asthma severity is assessed retrospectively from the level of

treatment required to control symptoms and exacerbations When?

Assess asthma severity after patient has been on controller treatment for several months

Severity is not static – it may change over months or years, or as different treatments become available

Categories of asthma severity Mild asthma: well-controlled with Steps 1 or 2 (as-needed SABA

or low dose ICS) Moderate asthma: well-controlled with Step 3 (low-dose

ICS/LABA) Severe asthma: requires Step 4/5 (moderate or high dose

ICS/LABA ± add-on), or remains uncontrolled despite this treatment

Assessing asthma severity

GINA 2017


Before starting initial controller treatment Record evidence for diagnosis of asthma, if possible Record symptom control and risk factors, including lung function Consider factors affecting choice of treatment for this patient Ensure that the patient can use the inhaler correctly Schedule an appointment for a follow-up visit

After starting initial controller treatment

Review response after 2-3 months, or according to clinical urgency

Adjust treatment (including non-pharmacological treatments)

Consider stepping down when asthma has been well-controlled for 3 months

Initial controller treatment

GINA 2017, Box 3-4 (2/2)


Stepwise management – pharmacotherapy(the therapy is designed to both prevent and relive

the obstruction)

*Not for children <12 years

**For children 6-11 years, the preferred Step 3 treatment is medium dose ICS

#For patients prescribed BDP/formoterol or BUD/ formoterol maintenance and reliever therapy

Tiotropium by mist inhaler is an add-on treatment for patients ≥12 years with a history of exacerbations

GINA 2017, Box 3-5 (2/8) (upper part)

Diagnosis

Symptom control & risk factors(including lung function)

Inhaler technique & adherence

Patient preference

Asthma medications

Non-pharmacological strategies

Treat modifiable risk factors

Symptoms

Exacerbations

Side-effects

Patient satisfaction

Lung function

Other controller

options

RELIEVER

STEP 1 STEP 2STEP 3

STEP 4

STEP 5

Low dose ICS

Consider low dose ICS

Leukotriene receptor antagonists (LTRA)Low dose theophylline*

Med/high dose ICSLow dose ICS+LTRA

(or + theoph*)

As-needed short-acting beta2-agonist (SABA) As-needed SABA or low dose ICS/formoterol#

Low dose ICS/LABA**

Med/high ICS/LABA

PREFERRED CONTROLLER

CHOICE

Add tiotropium*

High dose ICS + LTRA (or + theoph*)

Add low dose OCS

Refer for add-on

treatment e.g.

tiotropium,* anti-IgE, anti-IL5*

UPDATED 2017


Provide guided self-management education Treat modifiable risk factors and comorbidities Advise about non-pharmacological therapies and strategies

Consider stepping up if … uncontrolled symptoms, exacerbations or risks, but check diagnosis, inhaler technique and adherence first

Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who have exacerbations despite ICS treatment, provided FEV1 is 70% predicted

Consider stepping down if … symptoms controlled for 3 months + low risk for exacerbations. Ceasing ICS is not advised.

Stepwise management +


Low, medium and high dose inhaled corticosteroids Adults and adolescents (≥12 years)

This is not a table of equivalence, but of estimated clinical comparability Most of the clinical benefit from ICS is seen at low doses High doses are arbitrary, but for most ICS are those that, with prolonged use,

are associated with increased risk of systemic side-effects

Inhaled corticosteroid Total daily dose (mcg)Low Medium High

Beclometasone dipropionate (CFC) 200–500 >500–1000 >1000

Beclometasone dipropionate (HFA) 100–200 >200–400 >400

Budesonide (DPI) 200–400 >400–800 >800

Ciclesonide (HFA) 80–160 >160–320 >320

Fluticasone furoate (DPI) 100 n.a. 200

Fluticasone propionate (DPI or HFA) 100–250 >250–500 >500

Mometasone furoate 110–220 >220–440 >440

Triamcinolone acetonide 400–1000 >1000–2000 >2000

GINA 2017, Box 3-6 (1/2)


How often should asthma be reviewed? 1-3 months after treatment started, then every 3-12 months During pregnancy, every 4-6 weeks After an exacerbation, within 1 week

Stepping up asthma treatment Sustained step-up, for at least 2-3 months if asthma poorly controlled

• Important: first check for common causes (symptoms not due to asthma, incorrect inhaler technique, poor adherence)

Short-term step-up, for 1-2 weeks, e.g. with viral infection or allergen• May be initiated by patient with written asthma action plan

Day-to-day adjustment• For patients prescribed low-dose ICS/formoterol maintenance and reliever

regimen* Stepping down asthma treatment

Consider step-down after good control maintained for 3 months Find each patient’s minimum effective dose, that controls both

symptoms and exacerbations

Reviewing response and adjusting treatment

GINA 2017

*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol


A flare-up or exacerbation is an acute or sub-acute worsening of symptoms and lung function compared with the patient’s usual status

Consider management of worsening asthma as a continuum

Self-management with a written asthma action plan Management in primary care Management in the emergency department and hospital Follow-up after any exacerbation

GINA 2017


Increase inhaled reliever Increase frequency as needed Adding spacer (nebulizer) for pMDI may be helpful

Early and rapid increase in inhaled controller Up to maximum ICS of 2000mcg BDP/day or equivalent Options depend on usual controller medication and type of LABA See GINA 2017 report Box 4-2 for details

Add oral corticosteroids if needed Adults: prednisolone 1mg/kg/day up to 50mg, usually 5-7 days Children: 1-2mg/kg/day up to 40mg, usually 3-5 days Morning dosing preferred to reduce side-effects Tapering not needed if taken for less than 2 weeks Remember to advise patients about common side-effects (sleep

disturbance, increased appetite, reflux, mood changes)

Written asthma action plans – medication options

GINA 2017, Box 4-2 (2/2)

UPDATED 2017


Nebulizers, spacers


Patients with features of both asthma and COPD have worse outcomes than those with asthma or COPD alone Frequent exacerbations Poor quality of life More rapid decline in lung function Higher mortality Greater health care utilization

Reported prevalence of overlap varies by definitions used Concurrent doctor-diagnosed asthma and COPD are found in

15–20% of patients with chronic airways disease Reported rates of overlap are between15–55% of patients with

chronic airways disease, depending on the definitions used for ‘asthma’ and ‘COPD’, and the population studied

Prevalence varies by age and gender

Asthma-COPD overlap (ACO)

GINA 2017

UPDATED 2017


Definitions

GINA 2017, Box 5-1 (3/3)

Asthma

Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation. [GINA 2017]

COPD

Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. [GOLD 2017]

Asthma-COPD overlap [not a definition, but a description for clinical use]

Asthma-COPD overlap (ACO) is characterized by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD. Asthma-COPD overlap is therefore identified in clinical practice by the features that it shares with both asthma and COPD.This is not a definition, but a description for clinical use, as asthma-COPD overlap includes several different clinical phenotypes and there are likely to be several different underlying mechanisms.

UPDATED 2017

© Global Initiative for AsthmaGINA 2014 © Global Initiative for AsthmaGINA 2017, Box 5-4

SYNDROMIC DIAGNOSIS IN ADULTS(i) Assemble the features for asthma and for COPD that best describe the patient.(ii) Compare number of features in favour of each diagnosis and select a diagnosis

STEP 2

Features: if present suggest - ASTHMA COPD

Age of onset Before age 20 years After age 40 years

Pattern of symptoms Variation over minutes, hours or days

Worse during the night or early morning

Triggered by exercise, emotionsincluding laughter, dust or exposureto allergens

Persistent despite treatment

Good and bad days but always dailysymptoms and exertional dyspnea

Chronic cough & sputum preceded onset of dyspnea, unrelated to triggers

Lung function Record of variable airflow limitation(spirometry or peak flow)

Record of persistent airflow limitation(FEV1/FVC < 0.7 post-BD)

Lung function betweensymptoms

Normal Abnormal

Past history or family history Previous doctor diagnosis of asthma

Family history of asthma, and other allergic conditions (allergic rhinitis or eczema)

Previous doctor diagnosis of COPD,chronic bronchitis or emphysema

Heavy exposure to risk factor: tobaccosmoke, biomass fuels

Time course No worsening of symptoms over time.Variation in symptoms either seasonally, or from year to year

May improve spontaneously or have an immediate response to bronchodilators or to ICS over weeks

Symptoms slowly worsening over time(progressive course over years)

Rapid-acting bronchodilator treatmentprovides only limited relief

Chest X-ray Normal Severe hyperinflation

DIAGNOSIS

CONFIDENCE INDIAGNOSIS

Asthma

Asthma

Some featuresof asthma

Asthma

Features of both

Could be ACO

Some featuresof COPD

Possibly COPD

COPD

COPD

NOTE: • These features best distinguish between asthma and COPD. • Several positive features (3 or more) for either asthma or COPD suggestthat diagnosis. • If there are a similar number for both asthma and COPD, consider diagnosis of ACO

UPDATED 2017


Step 3 - Spirometry

Spirometric variable Asthma COPD Overlap

Normal FEV1/FVCpre- or post-BD

Compatible with asthma Not compatible withdiagnosis (GOLD)

Not compatible unlessother evidence of chronicairflow limitation

FEV1 ≥80% predicted Compatible with asthma(good control, or intervalbetween symptoms)

Compatible with GOLDcategory A or B if post-BD FEV1/FVC <0.7

Compatible with mildACO

Post-BD increase in FEV1 >12% and 400mLfrom baseline

- High probability ofasthma

Unusual in COPD.Consider ACO

Compatible withdiagnosis of ACO

Post-BD FEV1/FVC <0.7- Indicates airflowlimitation; may improve

Required for diagnosisby GOLD criteria

Usual in asthma-COPD overlap (ACO)

Post-BD increase in FEV1 >12% and 200mLfrom baseline (reversibleairflow limitation)

- Usual at some time incourse of asthma; notalways present

Common in COPD andmore likely when FEV1 is low

Common in ACO, andmore likely when FEV1 islow

FEV1<80% predicted Compatible with asthma.A risk factor for exacerbations

Indicates severity ofairflow limitation and riskof exacerbations and mortality

Indicates severity ofairflow limitation and riskof exacerbations and mortality

GINA 2017, Box 5-3

UPDATED 2017


If syndromic assessment suggests asthma as single diagnosis Start with low-dose ICS Add LABA and/or LAMA if needed for poor control despite good

adherence and correct technique Do not give LABA alone without ICS

If syndromic assessment suggests COPD as single diagnosis Start with bronchodilators or combination therapy Do not give ICS alone without LABA and/or LAMA

If differential diagnosis is equally balanced between asthma and COPD, i.e. asthma-COPD overlap Start treatment as for asthma, pending further investigations Start with ICS at low or moderate dose Usually also add LABA and/or LAMA, or continue if already

prescribed

Initial therapy

GINA 2017

UPDATED 2017

β 2 - β 2 - agonistsagonists Short-actingShort-acting::

Salbutamol Salbutamol Fenoterol Fenoterol TTerbutalineerbutaline

Long-actingLong-acting:: SSalmeterol almeterol Formoterol Formoterol IndakaterolIndakaterol

Medications to Treat Asthma: How to Use a Spray Inhaler

The health-care provider should evaluate inhaler technique at each visit.

Inhaled anticholinergicsInhaled anticholinergics

Short-actingShort-acting:: Ipratropium Ipratropium

bromidebromide ((AtroventAtrovent, , IpraventIpravent))

Tiotropium Tiotropium bromide bromide :: Tiotropium Tiotropium

bromidebromide ((SpirivaSpiriva))

Combined bronchodilatorsCombined bronchodilators

BetaBeta 2 - 2 - agonistagonist + anticholinergic: + anticholinergic:

• BerodualBerodual ( (fenoterolfenoterol + + ipratropium ipratropium bromidebromide))

• DuolinDuolin ((salbutamolsalbutamol + + ipratropium ipratropium bromidebromide))

MethylxanthinesMethylxanthines

Fast and short-Fast and short-actingacting: : EuphyllineEuphylline AminophyllineAminophylline

Long-actingLong-acting:: TeotardTeotard DoxofyllineDoxofylline

((Puroxan,Puroxan, AerofyllinAerofyllin) ) ......

Roflumilast:(Daxas®®), (DalirespTM)

Phosphodiesterase inhibitor with selective action on its isoenzyme IV (IFDE-4), which predominates in inflammatory cells

Shows anti-inflammatory activity in the airways:

• inhibits chemotaxis and activation of leukocytes, production of cytokines• reduces the number of neutrophils and eosinophils

Anti-inflammatory Anti-inflammatory medicines in medicines in

bronchoobstructive bronchoobstructive syndrome treatment syndrome treatment

Pulmonary rehabilitation of COPDPulmonary rehabilitation of COPD

Oxygen - Oxygen - a highly effective treatment for patients with a highly effective treatment for patients with stage III-IV COPD, the only one which is able to reduce stage III-IV COPD, the only one which is able to reduce mortalitymortality (A) (A)

Respiratory exercises Respiratory exercises provides only short-term effect provides only short-term effect (P)(P)

Physiotherapy unreasonable in COPD and useless in Physiotherapy unreasonable in COPD and useless in terms of evidence-based medicine treatment: light and terms of evidence-based medicine treatment: light and electrotherapy, bioresonance therapy, electric, electrotherapy, bioresonance therapy, electric, intranasal electrophoresis, UHF, iv laser irradiation and intranasal electrophoresis, UHF, iv laser irradiation and other (D)other (D)

No evidence is the use of acupuncture, homeopathy, No evidence is the use of acupuncture, homeopathy, herbal medicine.herbal medicine.

chronic obstructive lung disease (copd), … · globally, the copd burden is projected to increase...

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